An out-of-control client is verbally abusive and physically aggressive with staff members who are at increased risk for injury. Which intervention is most appropriate?
Take a time-out.
Administer oral medication.
Call a family member or friend.
Apply restraints.
The Correct Answer is D
A. Take a time-out: A time-out is generally used for de-escalating situations in less severe cases and may not be effective if the client is already physically aggressive and a risk to staff.
B. Administer oral medication: Administering oral medication can help to calm the client, but it may not be immediately effective if the client is already aggressive and out of control.
C. Call a family member or friend: Calling a family member or friend may provide emotional support, but it is not a direct intervention to address immediate physical aggression.
D. Apply restraints: When a client is physically aggressive and poses a risk of injury to themselves or others, applying restraints may be necessary to ensure safety. This should be done following proper protocols and as a last resort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Planning to give his CD collection to his girlfriend: Giving away prized possessions is a common warning sign of suicidal intent, indicating that the person is preparing for their absence.
B. Preferring to eat his meals while watching TV: This behavior is relatively normal and does not necessarily indicate suicidal intent.
C. Stating that he wants to be with his peers more than with his parents: Wanting to spend time with peers is typical for adolescents and does not specifically indicate suicidal intent.
D. Telling his parents that he doesn't want to talk about the attempt: Not wanting to discuss the attempt could be due to embarrassment, guilt, or other reasons, but it is not as direct an indicator of ongoing suicidal intent as giving away possessions.
Correct Answer is D
Explanation
A. Maintain eye contact until the behavior stops. Maintaining eye contact can be perceived as confrontational and may escalate the situation.
B. Tell the client her behavior is disappointing. Telling the client her behavior is disappointing is judgmental and not therapeutic.
C. Punish the client for the behavior. Punishing the client is not appropriate or therapeutic.
D. Leave the client's room. Leaving the room can help de-escalate the situation by removing the immediate trigger for the client's anger.
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